FORM SR (To be left blank by all Applicants) License No. Date Issued License Fee Received Name Location Classification (To be filed in by all Applicants) APPLICATION FOR RENEWAL OF LICENSE PURSUANT TO THE SALE OF CHECKS ACT TO: STATE OF ALABAMA Alabama Securities Commission 770 Washington Street, Suite 570 Montgomery, AL 36130-4700 DATE The undersigned hereby makes application for the renewal of a license under the provisions of the Sale of Checks Act, Act No. 177, Ala Code Section 8-7-1, et. al. to engage in the business of selling, issuing or otherwise dispensing checks, drafts, money orders or other instruments for the transmission or payment of money and/or the business of receiving money as agent for obligors for the purpose of paying such obligors' bills, invoices or accounts in the State of Alabama. For the purpose of such renewal application, the undersigned submits the following information: 1. The name of the Applicant is 2. The address of Applicant's principal office in the State of Alabama is: (Street) 3. (state) (Zip Code) If a foreign corporation, the address of the principal office of the corporation is: (City) 4. (City) (State) (Zip Code) The Trade Name(s) under which the Applicant proposes to operate, if any, is 5. Has the Applicant undergone any change in name or ownership since filing its original application with the Commission? If so, describe any such changes: American LegalNet, Inc. www.USCourtForms.com GENERAL QUESTIONS 1. Are you now engaged in the business of selling, issuing or otherwise dispensing checks, drafts, money orders or other instruments for the transmission or payment of money? YES NO Are you now engaged in the business of receiving money as agent for obligors for the purpose of paying 2. obligors' bills, invoices or accounts? YES 3. NO Do you carry on, or engage in any other business? YES NO If the answer is ''yes'', describe the other businesses: 4. Do you operate at more than one location within the State of Alabama? YES NO Number of additional locations (a) If your answer is ''yes", list each of these locations, provide the address of the location, and state the name and business address of your agents or representatives located at each location. This exhibit should be marked Exhibit A and attached to this application. DISCIPLINARY QUESTIONS DEFINITIONS: ''Applicant'' shall mean and include an individual applicant as well as the officers, directors and controlling persons of any proprietorship, corporation, partnership, limited liability corporation or joint stock association applicant. A. contest'') to: In the past ten years has the applicant been convicted of or pleaded guilty or nolo contendre (''no (1) A felony or misdemeanor involving: Investment or an investment-related business Fraud, false statement, or omission Wrongful taking of property or Bribery, forgery, counterfeiting, or extortion YES NO -2American LegalNet, Inc. www.USCourtForms.com (2) Any other felony? YES B. NO Has any other federal regulatory agency or any state regulatory agency: (1) Ever found the applicant to have made a false statement or omission or been dishonest, unfair, or unethical? YES NO (2) Ever found the applicant to have been a cause of a sales of check business having its authorization to do business denied, suspended, revoked, or restricted? NO YES business? (3) In the past ten years, entered an order against the applicant in connection with a sales of check NO YES (4) Ever denied, suspended, or revoked the applicant's registration or license, prevented it from associating with a sales of check business, or otherwise disciplined it by restricting its activities? YES NO THE APPLICANT, BY EXECUTING THIS APPLICATION, ACKNOWLEDGES AND AGREES TO THE FOREGOING CONDITIONS: A. The applicant agrees to operate its business in compliance with all orders, decisions, or findings of the Alabama Securities Commission. YES NO B. The applicant agrees to maintain adequate records which disclose the true status of the Applicant's business and will make such records available for examination upon request of representatives of the Alabama Securities Commission. YES NO C. Applicant agrees to maintain sufficient bank deposit balances at all times to cover Applicants liability on account of checks, drafts, money orders or other instruments for the transmission or payment of money and the receiving of money as agent for obligors. YES NO D. Applicant agrees to deliver to the Alabama Securities Commission the license issued by the Commission if the same is not renewed or if the license is revoked or voluntarily surrendered. YES NO -3American LegalNet, Inc. www.USCourtForms.com E. Applicant agrees that, upon receiving a license under the Act, it will maintain a bank deposit account for the payment of liabilities incurred in the business for which this license application is being filed. Applicant will keep and maintain in this account, at all times, a minimum amount equal to all outstanding liabilities. YES NO SIGNATURE OF APPLICANT For sole proprietor (Proprietor) For partnership (Name of partnership) BY (General Partner) (Seal of Corporation) For Corporation, etc. (Name of Corporation) BY (Name) ITS: Title For Limited Liability Corporation, Limited Liability Partnership BY (Its Managing Member/Shareholder) This application must be executed by a principal officer, partner or principal on behalf of the Applicant. -4American LegalNet, Inc. www.USCourtForms.com ) STATE of SS. ) COUNTY OF The undersigned being duly sworn deposes and says that he has executed the foregoing application for and on behalf of the applicant named therein; that he is of such applicant and is fully authorized to execute and file such application; that he is familiar with such application; and that to the best of his knowledge, information and belief, the statements made in such application and the statements made in the exhibits submitted therewith, are true. Subscribed and sworn to before me this day of , 19 . (Notary Public) -5American LegalNet, Inc. www.USCourtForms.com